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Background The benefits of using thin acetabular components for hip resurfacing have been shown in terms of bone conservation, but there currently are little data available in the literature addressing the mid-term clinical results of these devices. Questions/purposes We aimed to determine whether thinner acetabular components altered mid-term postoperative clinical scores, complication rates, survivorship, radiographic appearance, and metal ion levels. Methods Two hundred eighty-one patients with unilateral disease received a 5-mm thick acetabular shell and 223 received a 3.5-mm shell. The femoral component implanted in both groups was identical. We compared clinical scores, complication rates, survivorship, radiographic results, and ion levels between these two groups. Results UCLA hip scores were similar (pain, p = 0.0976; walking, p = 0.9571; function, p = 0.9316; activity, p = 0.2085). Complications were higher in the 5-mm group (6.4% versus 1.8%, p = 0.0431). Both groups were similar regarding survivorship (p = 0.3181), cup radiolucency at 5 years (p = 0.107), and metal ion levels (cobalt p = 0.404, chromium p = 0.250). Conclusions With comparable mid-term clinical results,